VI PEEL INTAKE CONSENT FORM

VI PEEL INTAKE AND CONSENT FORM
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The VI Peel contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peels will improve the tone, texture and clarity of the skin: reduces age spots, improve hyperpigmentation including melasma, soften lines and wrinkles:clear acneic skin conditions: reduce or eliminate scars: and stimulate the production of collegen for firmer more youthful skin.

****Contraindications****

Patients who are pregnant or who are breast feeding
Patients who have an aspirin, hydroquinone or phenol allergy
Patients who have used oral isotretinoin (Accutane) within the past 6 months
Patients who have active cold sores, warts, open wounds or history of herpes simplex
Patients who are undergoing chemotherapy and or radiation therapy within 6 months
Patients with a history of an autoimmune or liver disease/disorder as well as any condition that may weaken their immune system

*** If you have a history of cold sores, fever blisters, or herpes; please start your medication one day prior to your treatment and take the full course of medication as prescribed by your physician***
Do you have any of the following:*

CancerPregnantBreast feedingHepatitis or Liver diseaseAllergies or sensitivityHerpes, Cold Sores, Fever Blisters
Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.I understand that there may be some degree of discomfort such as burning, stinging, redness, heat or tightness during and a week after the procedure.I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment.Iunderstand if I have any acneic condition in the skin the peel maybring out oils and bacteria from below the surface and can cause anactual breakout.I under stand that maintenance of VI Peel™ treatments are necessary to maintain results as well as the recommended VI DERM™ skin care regimen and SPF50+I understand that no other chemical peels, facial machine brushes ormedical device (laser, IPL, etc) treatments may be performed on myskin until my physician/clinician releases me to do so.I understand that this is an elective cosmetic procedure.I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel.I understand that I must protect my skin with VI DERM™ SPF 50+and avoid sun exposure during the 7 day exfoliation processI understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub steam room)
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VI PEEL INTAKE AND CONSENT FORM